scholarly journals POS0980 ANALYSIS OF PRIMARY CARE CONSULTATION PATTERNS TO AID DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS – AN EXPLORATORY CASE SERIES

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 757-757
Author(s):  
M. Al-Attar ◽  
W. J. Gregory ◽  
J. Mcbeth ◽  
W. Dixon
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Delayed Diagnosis ◽  
Primary Care Consultation ◽  
Undiagnosed Disease ◽  
Joint Symptoms ◽  
Care Consultation ◽  
Axial Symptoms

Background:Patients with Axial Spondyloarthritis (AxSpA) often suffer a significant delay to diagnosis. This is associated with poorer outcomes in quality of life, functional capabilities and work productivity [1]. These patients are frequent consulters to primary care in the years preceding rheumatology referral [2]. We hypothesise that analysis of primary care consultation patterns may identify as-yet undiagnosed disease, and suggest that implementing an automated diagnostic algorithm may support early action in primary care.Objectives:To undertake a preliminary exploration of primary care consultation patterns in patients with a delayed diagnosis of AxSpA and identify themes for further research.Methods:The study was run in Salford, UK, where unique linkage exists across electronic health records (EHR) from primary and secondary care. A dataset of patients with AxSpA was obtained from 2018-2020 hospital physiotherapy clinic records. Ten patients with a time to diagnosis ≥ 5 years were randomly selected for this exploratory analysis. Diagnostic delay was calculated based on rheumatology clinic letter documentation. Age, sex, and HLA-B27 status were recorded. All “Problem” codes from the primary care EHR up to the point of diagnosis were manually reviewed.Results:Age at diagnosis was 32-49 years with seven males and three females. Seven were HLA-B27 positive. The average delay to diagnosis was 15.8 years (range 5-30).On average, patients had 15 primary care consultations (range 5-24) between first coded AxSpA-related symptom and rheumatology referral. Around half of these codes were potentially AxSpA-related (for example, see Figure 1).Six patients had a coded history of back pain. Two patients presented with other axial symptoms, including: rib pain, MSK chest pain and sciatica.Five patients presented with peripheral joint symptoms, including: ankle pain, shoulder pain, knee problem, pain in arm, medial epicondylitis elbow, hip pain and groin pain. Of these, four had multiple presentations and three had a previous visit with axial pain.Two patients had uveitis preceding axial symptoms. One patient had peripheral joint symptoms (hip pain) preceding uveitis.Inconsistent codes were used for the same problem presenting at different times in nine cases, including: back pain, backache, low back pain, lower back pain.Other relevant codes were used in seven cases, including: stiffness, arthritis, saw physiotherapist and referred to pain clinic.Figure 1 illustrates the consultation pattern for a male patient who first presented to primary care with back pain at the age of 35. Despite a relatively typical presentation, his diagnosis was made incidentally 10 years later after an ESR was checked for unrelated reasons. He was significantly disabled in function at the point of being referred to rheumatology.Conclusion:Our preliminary analysis suggests that patients with a delayed diagnosis of AxSpA have repeated primary care visits with potentially recognisable symptoms of their disease. These findings support the feasibility of future automated detection, with areas of focus including recognition of non-back pain axial symptoms, extra-articular manifestations, and peripheral joint symptoms.Whilst half of presentations were not directly AxSpA-related, modern machine learning techniques have the ability to explore whether the pattern or frequency of these consultations are relevant to identifying undiagnosed disease. Such methods can also highlight patterns obscured by extensive data sets and inconsistent coding, with opportunity for implementation back into primary care.References:[1]Redeker I et al. Determinants of diagnostic delay in axial spondyloarthritis: an analysis based on linked claims and patient-reported survey data. Rheumatology (Oxford) 2019;58:1634–8.[2]Yi E et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020;7(1):65–87Disclosure of Interests:None declared.

scholarly journals O21 Unrecognised inflammatory back pain: a retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed axSpA

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Authors: Carol McCrum ◽  
Karen Kenyon ◽  
Julie Cleaton
Keyword(s):  
Back Pain ◽  
Clinical Practice ◽  
Professional Education ◽  
Retrospective Review ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Delayed Diagnosis ◽  
Inflammatory Back Pain ◽  
Diagnostic Code ◽  
Quality Of Life Research

Abstract Background Axial spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5-8 years with impacts on effective and timely management, outcomes and quality of life. Research on diagnostic delay suggests that a lack of recognition of inflammatory back pain and possible axSpA has been a contributing factor. Published referral criteria including NICE guidance (2017) and quality standards (2018) on spondyloarthritis in over-16s highlight the importance of earlier diagnosis and were developed to support earlier recognition and referral of suspected axSpA in primary care settings. This aim of this study was to investigate the occurrence of referral for musculoskeletal physiotherapy care and treatment prior to diagnosis of axSpA and to evaluate levels of recognition. Methods A retrospective review was undertaken of all patients diagnosed with axSpA who had been referred to and received physiotherapy care within nine physiotherapy services prior to diagnosis (1990-2016). Unrecognised axSpA was taken as the individual referred for and receiving three or more episodes of physiotherapy prior to diagnosis. Data was obtained on assigned diagnostic codes, number of episodes of physiotherapy care and contacts per episode. Results Two hundred and sixty three (263) people diagnosed with axSpA (age range 17-69 years) had been referred by a GP and received physiotherapy care prior to their diagnosis. Within this axSpA population, 103 (44%) had received 3 or more musculoskeletal physiotherapy assessments and episodes of care. Number of treatment contacts within each care episode ranged from 3 (47 people) to 58 contacts (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy care episode to date of diagnosis was 6.4 years (range=0.3-12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Analysis indicates that in nearly half of individuals who came to be diagnosed with axSpA, features of inflammatory back pain and possible axSpA were not recognised on at least six or more assessment occasions by either referrers or treating clinicians. Conclusion This study illustrates the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal clinical practice. This lack of recognition highlights the importance of professional education on signs, symptoms and risk factors for axSpA to support earlier diagnosis and treatment. Screening for and recognition of inflammatory back pain and other features for when to suspect and refer for possible axSpA in assessments of people with back pain need to be part of routine musculoskeletal clinical practice. Further research into contributors to diagnostic delay and the most effective education strategies to support earlier recognition of axSpA is needed. Disclosures C. McCrum: Honoraria; Novartis. K. Kenyon None. J. Cleaton None.

scholarly journals Primary care physician perspectives on barriers to diagnosing axial Spondyloarthritis: a qualitative study

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Kate L. Lapane ◽  
Sara Khan ◽  
Divya Shridharmurthy ◽  
Ariel Beccia ◽  
Catherine Dubé ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Primary Care Physicians ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Patient Characteristics ◽  
Inflammatory Back Pain ◽  
Average Delay ◽  
Disease Characteristics ◽  
Pain Clinics

Abstract Background The average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians. Methods We conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview (< 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA. Results Physicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and “doctor shopping.” Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists. Conclusion Primary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors).

scholarly journals REASONS FOR DIAGNOSTIC DELAYS OF AXIAL SPONDYLOARTHRITIS

2019 ◽  
Vol 72 (9) ◽  
pp. 1607-1610
Author(s):  
Robert Zwolak ◽  
Dorota Suszek ◽  
Aleksandra Graca ◽  
Marcin Mazurek ◽  
Maria Majdan
Keyword(s):  
Back Pain ◽  
Ankylosing Spondylitis ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Connective Tissue Diseases ◽  
Inflammatory Back Pain ◽  
Hla B27 ◽  
History Of ◽  
Axial Symptoms ◽  
Diagnostic Delays

Introduction: The probability of development of axial spondyloarthritis (axSpA) is estimated to be above 90% among patients with chronic back pain, presence of HLA B27 antigen and positive family history of ankylosing spondylitis (AS), psoriasis, reactive arthritis, inflammatory bowel disease or uveitis. The nonradiographic axSpA and ankylosing spondylitis diseases’ activity has a comparable impact on the patients’ quality of life and from the practical point of view the approach to treatment of each of them is the same. The aim: The attempt to identify the reasons of diagnostic delays of AS among patients hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin and to suggest the ways of improving the accuracy of diagnostic track among other healthcare providers than rheumatologists. Material and methods: We performed a retrospective analysis of the records of 82 patients’ with the established diagnosis of AS, hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin in 2000-2019, and of 45 years of age and older. Results: From among 82 patients (28 women and 54 men) the diagnosis of AS after 45 years of age was established in 25 patients (10 women and 15 men) – group t, and in the other 57 patients (group n) the diagnosis was established before 45 years of age. On average the age at the time of diagnosis in the whole group (t+n) was 40,7±10,2 (18-76) years, the age at the beginning of inflammatory back pain (age of axial symptoms) was 30,9±8,5 (13-51) years and the diagnostic delay (period between first axial symptoms and diagnosis establishment) was 9,75±9,5 (0-46) years. We did not find any statistically significant associations between sex and age at the moment of diagnosis, age of the beginning of axial symptoms and the time of diagnostic delay. There was no significant difference of incidence of enthesitis, uveitis, arthritis, prevalence of family history of spondyloarthritis and CRP level between group t and n. Antigen HLA B27 was more frequently present in group t. Conclusions: Instead of the recognition progress and worldwide popularization of knowledge about axSpA, the diagnostic delays in this field are still estimated to last many years, the patients are looking for other specialists’ help, and they can be not knowledgeable of the inflammatory back pain criteria. Currently, HLA B27 antigen and C-reactive protein are the two most commonly used biomarkers for diagnostic and disease activity monitoring purposes of axSpA and magnetic resonance is the only “imaging biomarker” The presence of extra-axial symptoms does not improve the diagnostic sensitivity.

scholarly journals THU0560 PRIMARY CARE PHYSICIAN PERSPECTIVES ON DELAYS IN DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS: A QUALITATIVE STUDY

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 521.1-521
Author(s):  
S. H. Liu ◽  
K. Lapane ◽  
D. Shridharmurthy ◽  
S. Khan ◽  
K. Ferrucci ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Primary Care Physicians ◽  
Laboratory Tests ◽  
Screening Tool ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Inflammatory Back Pain ◽  
Research Support ◽  
Average Delay

Background:The average delay in diagnosis for patients with any form of spondyloarthritis (SpA) ranges from 7 to 10 years [1–5]. In axial spondyloarthritis (axSpA), a subgroup of SpA, it is 5 to 14 years [4, 6, 7]. Factors that contribute to this delay include the lack of diagnostic criteria for axSpA and the difficulty in distinguishing inflammatory back pain (IBP), a key symptom of axSpA, from other highly prevalent forms of low back pain [8–10]. This impedes timely referral of these patients to rheumatologic care and initiation of appropriate treatment.Objectives:Describe understanding of, attitudes towards, and practices regarding axSpA among primary care physicians.Methods:We recruited 18 primary care physicians practicing in the United States as part of a larger qualitative study: theSpondyloArthritisScreening andEarlyDetection (SpA-SED) Study. We used purposive sampling with a goal of including an equal number of family medicine and internal medicine physicians who were balanced by gender. Physicians provided informed consent to participate in an in-depth interview (up to 60 minutes), conducted in person (n = 3) or over the phone (n = 15), between February and May 2019. The interview guide was developed by a multidisciplinary team, with input from rheumatologists. Topics included the physicians’ approaches to evaluating back pain, their awareness about axSpA, their differential diagnosis of axSpA, the laboratory tests and imaging studies ordered when axSpA is suspected, their referral patterns for patients with presumed axSpA, their thoughts about factors contributing to diagnostic delay in axSpA, and their opinions about an Inflammatory Back Pain Assessment – ASAS criteria screening tool [5].Results:Barriers to early diagnosis included patient factors (eg, multiple complaints, back pain not being the chief complaint), disease characteristics (eg, slow rate of disease progression), physician characteristics (eg, lack of rapport between patients and their primary care physicians), and structural/system issues (eg, lack of time). Most physicians reported that they would perform laboratory tests before referring a patient to a rheumatologist.Conclusion:Primary care physicians were surprised to learn of the average delay to axSpA diagnosis, considered that this lengthy delay was problematic, and agreed that improvements are needed in screening for and early detection of axSpA. Physicians believed that there would be a role for using a screening tool in the primary care setting to improve diagnostic delay, but that evidence to support its implementation is needed.References:[1]Dougados M et al.Arthritis Rheum.1991;34:1218–27.[2]Amor B et al.Rev Rhum Mal Osteoartic.1990;57:85–9.[3]van der Linden S et al.Arthritis Rheum.1984;27:361–8.[4]Deodhar A et al.Arthritis Rheumatol.2016;68:1669–76.[5]Sieper J et al.Ann Rheum Dis.2009;68:784–8.[6]Sykes MP et al.Rheumatology (Oxford).2015;54:2283–4.[7]Redeker I et al.Rheumatology (Oxford).2019;58:1634–8.[8]Strand V et al.Mayo Clin Proc.2017;92:555–64.[9]Proft F et al.Ther Adv Musculoskelet Dis. 2018;10:129–39.[10]Bohn R et al.Clin Exp Rheumatol.2018;36: 263–74.Acknowledgments:We thank the participants for sharing their insights as part of this study. This abstract was written using data from a research study originally funded by Novartis (Principal Investigator: Shao-Hsien Liu, Co-Investigators: Jonathan Kay, Kate Lapane, Catherine Dubé).Disclosure of Interests:Shao-Hsien Liu Grant/research support from: Novartis Pharmaceuticals Corporation, Kate Lapane Grant/research support from: Novartis Pharmaceuticals Corporation, Divya Shridharmurthy Grant/research support from: Novartis Pharmaceuticals Corporation, Sara Khan Grant/research support from: Novartis Pharmaceuticals Corporation, Katarina Ferrucci Grant/research support from: Novartis Pharmaceuticals Corporation, Catherine Dubé Grant/research support from: Novartis Pharmaceuticals Corporation, Esther Yi Employee of: Novartis Pharmaceuticals Corporation, Jonathan Kay Grant/research support from: Gilead Sciences, Inc., Pfizer, Novartis Pharmaceuticals Corporation, Consultant of: Alvotech Suisse AG; Arena Pharmaceuticals, Inc.; Boehringer Ingelheim GmbH; Celltrion Healthcare Co. Ltd.; Merck Sharp & Dohme Corp.; Mylan Inc.; Novartis AG; Samsung Bioepis; Sandoz, Inc; UCB, Inc.

scholarly journals POS0059-PARE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS – TIME FOR A GOLD STANDARD APPROACH

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 235.3-236
Author(s):  
D. Webb ◽  
K. Gaffney ◽  
R. Sengupta ◽  
S. S. Zhao ◽  
L. Swingler
Keyword(s):  
Primary Care ◽  
Gold Standard ◽  
Axial Spondyloarthritis ◽  
Public Awareness ◽  
Delayed Diagnosis ◽  
Research Support ◽  
Professional Societies ◽  
Standard Time ◽  
Time To Diagnosis ◽  
The Uk

Background:In the UK, the average time to diagnosis of axial SpA is 8.5 years (1). There is little evidence this has improved, despite the acceptance of MRI use in diagnosis (2). A recent review identified significant clinical, economic and humanistic burden from delayed diagnosis (3). Urgent action is needed to ensure delayed diagnosis is not normalized.Objectives:We created a proposal for a Gold Standard time to diagnosis for axial SpA and a national implementation plan (4) through consensus development with patients, healthcare professionals and professional bodies.Methods:A.A scoping literature review identifying where delays occur, from first symptom onset to diagnosis by a rheumatologist, and potential solutions. From this, a summary report / draft plan was produced for consultationB.A national consultation survey to elicit views on the proposals from clinicians, healthcare professionals, professional societies and patientsC.Structured feedback to written proposals via e-consultation with clinicians and patientsD.A consensus development workshop to finalise the Gold Standard and implementation plan.Results:The literature review identified four delays:1. People do not know axial SpA may be a cause of their chronic back pain2. Primary care practitioners may not recognise features of axial SpA3. People may be referred to non-rheumatologists who may not recognise axial SpA promptly4. Rheumatology and radiology teams may not optimally request or interpret investigations.202 participants responded to the summary report (74% patients, 21% healthcare professsionals, 5% professional societies). All supported the principles behind the gold standard time to diagnosis. Qualitive analysis confirmed agreement with the proposed solutions, underscoring the importance of education and visibility for axial SpA within primary care and increased public awareness. Additional proposals were suggested, including a tool in primary care to run audits on IT systems.40 clinicians contributed to the e-consultation and 55 clinicians, policy makers, social marketing experts, health journalists and patients attended the consensus workshop. Consensus was reached on a gold standard time to diagnosis of one year, and the principles, key components and phasing of the implemention plan. This included: public awareness about axial SpA symptoms; a primary care clinical champions programme; creating a referral pathway from primary care direct to rheumatology; a secondary care service educational programme.Conclusion:There is consensus from UK axial SpA clinicians, patients and professional societies on the need for a Gold Standard time to diagnosis of axial SpA of one year, so that patients can live happy, healthy and productive lives.References:[1]Hamilton L, Gilbert A, Skerett J, et al. Services for people with ankylosing spondylitis in the UK - a survey of rheumatologists and patients. Rheumatology 2011:50:1991[2]Sykes MP, Doll H, R Sengupta, Gaffney, K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology, July 2015[3]Yi E, Ahuja A, Rajput T, et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020 Mar;7(1):65–87.[4]Webb D, Zhao S, Whalley S, et al. Gold Standard Time to Diagnosis in axial Spondyloarthritis: Consultation Document. 2020, NASS.Disclosure of Interests:Dale Webb Speakers bureau: Janssen, Novartis, Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB, Karl Gaffney Speakers bureau: Abbvie, Lilly, Novartis, UCB, Consultant of: Abbvie, Celltrion, Lilly, Grant/research support from: Abbvie, Pfizer, Lilly, UCB, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, Sizheng Steven Zhao: None declared, Lisa Swingler Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB.

scholarly journals Soliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: A qualitative study

2016 ◽  
Vol 99 (5) ◽  
pp. 724-732 ◽  
Author(s):  
Rachael H. Summers ◽  
Michael Moore ◽  
Stuart Ekberg ◽  
Carolyn A. Chew-Graham ◽  
Paul Little ◽  
...  
Keyword(s):  
Primary Care ◽  
Qualitative Study ◽  
Communication Intervention ◽  
Primary Care Consultation ◽  
Care Consultation

scholarly journals External Validation of a Referral Rule for Axial Spondyloarthritis in Primary Care Patients with Chronic Low Back Pain

PLoS ONE ◽  
2015 ◽  
Vol 10 (7) ◽  
pp. e0131963 ◽  
Author(s):  
Lonneke van Hoeven ◽  
Yvonne Vergouwe ◽  
P. D. M. de Buck ◽  
Jolanda J. Luime ◽  
Johanna M. W. Hazes ◽  
...  
Keyword(s):  
Primary Care ◽  
Low Back Pain ◽  
Back Pain ◽  
Chronic Low Back Pain ◽  
Axial Spondyloarthritis ◽  
External Validation ◽  
Low Back ◽  
Primary Care Patients

Spinal infections

2018 ◽  
Vol 11 (8) ◽  
pp. 448-451
Author(s):  
Shrijit Panikkar ◽  
Chitra V Nair
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Small Proportion ◽  
Delayed Diagnosis ◽  
Spinal Infection ◽  
Significant Morbidity ◽  
Presenting Symptoms ◽  
Underlying Causes ◽  
High Index Of Suspicion ◽  
Spinal Infections

Spinal infection is a rare cause of back pain that can have devastating consequences if left untreated. Since back pain can be the only symptom in early spinal infection diagnosing it is a major challenge in primary care, where back pain accounts for 6–9% of consultations. Most episodes of back pain, which has an annual incidence of 2–5%, are mechanical in nature and are self-limiting. Only a small proportion of back pain is due to serious underlying causes such as infection, neoplasia and fractures. GPs need to be aware of the presenting symptoms of spinal infection and who is at risk, as a high index of suspicion is needed to avoid the significant morbidity and mortality associated with delayed diagnosis.

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